19.1 Geriatrics

Geriatrics is the largest single slice of the Associated Clinical Sciences domain on NBCE Part II at roughly 15% of ACS content. Older adults are also the fastest-growing patient population in chiropractic practice, so the boards test whether you can distinguish normal aging from disease, recognize atypical presentations, and modify management safely. Items reward specific numbers — the orthostatic hypotension threshold, hip-fracture mortality, and the features that separate delirium from dementia — and applied vignettes about whether manipulation is appropriate.

Normal Aging: Anatomy and Physiology

Aging is a universal, progressive decline in physiologic reserve sometimes called homeostenosis. It is not disease, but it narrows the margin between compensation and decompensation, so a minor infection, medication change, or day of poor hydration can produce disproportionate decline.

Cardiovascular

Baroreceptor sensitivity decreases, arterial stiffness increases, and resting systolic blood pressure tends to rise while diastolic pressure may fall — widening pulse pressure. Maximum heart rate during exertion declines (220 minus age is a rough ceiling). These changes predispose elders to orthostatic hypotension and reduced exercise tolerance.

Respiratory

Chest-wall compliance decreases, residual volume increases, and the cough reflex weakens. Pneumonia in an older adult may present without fever or productive cough — only confusion and fatigue.

Renal and Hepatic

Glomerular filtration rate declines roughly 1 mL/min/1.73 m² per year after age 30, slowing drug clearance. Hepatic phase I metabolism decreases, prolonging the half-life of many medications. Dose adjustment and deprescribing become essential.

Musculoskeletal

Sarcopenia — age-related loss of skeletal muscle mass and strength — accelerates after age 60. Adults lose roughly 3–8% of muscle mass per decade after 30. Bone mineral density falls, especially in postmenopausal women, raising fracture risk. Intervertebral discs desiccate and lose height; facet arthropathy and spinal stenosis become common.

Neurologic and Sensory

Reaction time slows, proprioception diminishes, and vibratory sense in the feet decreases — all contributing to gait instability. Vision changes (cataracts, macular degeneration) and hearing loss reduce environmental awareness. Presbycusis and reduced contrast sensitivity are under-recognized fall risks.

Immune

Immunosenescence blunts the febrile response; a serious infection may present with subtle behavioral change rather than high fever.

Geriatric Disorders: High-Yield Recognition

Delirium Versus Dementia

This distinction appears on nearly every Part II administration:

Delirium is a medical emergency until proven otherwise. In the chiropractic office, new confusion in an established patient should halt treatment and trigger referral — not reassurance that they are "just getting older."

Frailty and Falls

Frailty is a clinical syndrome of decreased reserve across multiple systems, often operationalized by unintentional weight loss, exhaustion, weakness, slow gait, and low activity. Falls are the leading cause of injury death in adults 65 and older; hip fracture carries roughly 20–30% one-year mortality.

Common fall contributors the boards test:

• Orthostatic hypotension — drop ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing
• Polypharmacy — generally defined as five or more medications
• Benzodiazepines, opioids, antihypertensives, and anticholinergics
• Home hazards: throw rugs, poor lighting, absence of grab bars

Polypharmacy and the Beers Criteria

The AGS Beers Criteria list potentially inappropriate medications (PIMs) in adults 65 and older. High-yield PIMs for the exam:

Geriatric Case Management in Chiropractic Practice

Functional Assessment

Before adjusting an older adult, assess activities of daily living (ADLs) — bathing, dressing, toileting, transferring, continence, feeding — and instrumental ADLs (IADLs) — managing medications, finances, shopping, meal preparation. Decline signals need for co-management with primary care, social work, or geriatrics.

Modifying the Chiropractic Encounter

• Use gentler, lower-force techniques when osteoporosis, anticoagulation, or severe degenerative disease is present
• Allow extra time for positioning; avoid rapid supine-to-sitting transitions in patients with orthostasis
• Screen for yellow flags that may be atypical cardiac, neurologic, or infectious presentations
• Document fall history, assistive devices, and caregiver concerns

When to Refer

Immediate referral is warranted for acute delirium, suspected abuse or neglect, unwitnessed head trauma with anticoagulation, new focal neurologic deficit, chest pain or dyspnea, and suspected hip fracture (shortened, externally rotated leg; inability to bear weight).

Preventive Counseling Within Scope

Encourage resistance and balance exercise (tai chi is evidence-supported for fall prevention), vitamin D supplementation when deficient, medication review with the prescribing physician, home safety evaluation, and annual vision and hearing checks. These are wellness interventions that align with chiropractic health promotion without crossing into medical management.

Key Exam Patterns

Geriatrics vignettes often describe a patient whose "back pain" is actually a compression fracture, whose "dizziness" is orthostatic hypotension from a new antihypertensive, or whose daughter reports sudden personality change that is delirium from a urinary tract infection. The correct answer is almost always recognition and referral, not continued passive care.